estate planning questionnaire for use by...

MELANSON LAW PA 1

ESTATE PLANNING QUESTIONNAIRE FOR USE BY MELANSON LAW PA

Your appointment is at _________ on _________________________, 2015. Bring this completed form and your current estate planning documents to our office at or before your scheduled meeting time. Please complete this form to the best of your ability before the appointment. Without the fully completed questionnaire, we may be unable to discuss your situation with you and may need to reschedule your appointment.

Whom may we thank for your referral to our firm? _____________________________________

PERSONAL INFORMATION

Please write out the names as you would like them to appear on your documents.

1. Name (CLIENT 1): _______________________________________________________

2. CLIENT 1 date/place of birth: _______________________________________________

3. Spouse's name (CLIENT 2): ________________________________________________

4. CLIENT 2 date/place of birth: _______________________________________________

5. Home address: ___________________________________________________________

6. Home telephone number: ___________________________

7. Work telephone number: ___________________________

8. Mobile telephone number: __________________________

9. E-mail address: ____________________________________

10. CLIENT 1 employer: _______________________________

11. CLIENT 2 employer: _______________________________

12. Are you a resident of Florida? [ ] Yes [ ] No If yes, since __________________

13. Retired? [ ] Yes [ ] No

14. Marital Status: [ ] Single [ ] Divorced [ ] Married [ ] Widowed

Date of Marriage: ____________ Place of Marriage: ________________________

15. If widowed, please complete the following regarding your deceased spouse:

Name: __________________________________________

Date of death: ____________________________________

State/City/County of death: __________________________

Birthdate: ______________________

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16. If you have a financial planner, please list their contact information here:

Name: ________________________________ Company: _____________________________ Phone number: _________________________

17. If you have an accountant, please list their contact information here:

Name: ________________________________ Company: _____________________________ Phone number: _________________________

WILL

18. CHILDREN: Please list all children. Also list children who predecease you, if any, and their children.

CLIENT 1 CHILDREN: CLIENT 2 CHILDREN:

Name: __________________________________ Date of birth: _____________________________ Address: ________________________________ ________________________________________ Telephone number: ________________________ Spouse’s name: ___________________________ Children’s names/ages:______________________ ________________________________________




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19. OTHER BENEFICIARIES: Please list the names and addresses of beneficiaries other

than children. If you are leaving funds to a charity, please provide the complete name, address, and telephone number for the charity. Please call the charity’s office and ask them to send you a copy of their IRS 501(c)(3) letter, and bring that to your appointment. CLIENT 1 BENEFICIARIES: CLIENT 2 BENEFICIARIES:

Name: __________________________________ Relationship:_____________________________ Address: ________________________________ ________________________________________ Telephone number:________________________








20. Do you have any pets? [ ] Yes [ ] No

Have you made arrangements for your pet at your death? [ ] Yes [ ] No

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21. Are any of your children adopted? [ ] Yes [ ] No

22. Does anyone to whom you are leaving part of your estate receive Social Security Disability Benefits (SSDI), Supplemental Security Income (SSI), Medicaid, Medicare, or another benefit? [ ] Yes [ ] No

If yes, please indicate the type and the amount: ___________________________________

________________________________________________________________________

23. Do you have any certain personal items, property, or gifts that you would like to leave to specific people?

CLIENT 1: CLIENT 2:

I give: ___________________________________ To: _____________________________________ Relationship: _____________________________ Address: _________________________________ ________________________________________





I give: ___________________________________ To: _____________________________________ Relationship: _____________________________ Address: _________________________________ _________________________________________



24. Your desired funeral arrangements:

a. Do you have any present arrangements? [ ] Yes [ ] No

b. Do you have a pre-paid funeral plan? [ ] Yes [ ] No

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c. Preferred funeral home (if any):

Name: _______________________________________________________ Location: ____________________________________________________

25. Do you desire cremation? CLIENT 1: [ ] Yes [ ] No

CLIENT 2: [ ] Yes [ ] No

26. Who do you want to serve as your personal representative (Executor of Will)? This

person is responsible for making sure that the wishes expressed in your will are carried out according to law. This person must be: over the age of 18, legally able to sign a contract, not a convicted felon, and either a Florida resident OR a blood relative. It is important to specify an alternate personal representative, especially if your first choice is your spouse or someone older than you, as they may not be available at the time your estate is probated. If you do not specify a personal representative, the Court will appoint one for you, typically a family member for whom it is most convenient, or an attorney who routinely handles estates. CLIENT 1 PR: CLIENT 2 PR:


Name: ___________________________________ Relationship:______________________________ Address: _________________________________ _________________________________________ Telephone number:_________________________

27. If the above named cannot serve for any reason, who would be your next choice?

CLIENT 1 PR: CLIENT 2 PR:





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DURABLE POWER OF ATTORNEY

Durable Power of Attorney: A document for your agent to handle all financial aspects for you during your lifetime, including if you are unable to do so.

28. Who would you want to manage your assets (name as your Power of Attorney)? List in order of priority. Please note if you want your agents to act cooperatively.

CLIENT 1: CLIENT 2:

First Agent: Name: ___________________________________ Relationship: _____________________________ Address: _________________________________ ________________________________________ Telephone number: ________________________


Second Agent: Name: ___________________________________ Relationship: _____________________________ Address: _________________________________ ________________________________________ Telephone number: ________________________


Third Agent: Name: ___________________________________ Relationship: _____________________________ Address: _________________________________ ________________________________________ Telephone number: ________________________


HIPAA

HIPAA Authorization: A document that allows the people listed to have access to your health information.

29. Who do you wish to have access to your health information (in no particular order)?

CLIENT 1: CLIENT 2:

Name: Name:

Name: Name:

Name: Name:

Name: Name:

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COMPREHENSIVE ADVANCE HEALTH CARE DIRECTIVE

A Living Will: A document indicating that you do not want unnecessary life support systems to sustain your life, should you have an incurable or irreversible condition that would otherwise cause death in a short period of time.

Designation of Health Care Surrogate: A document that will indicate who will make health care decisions for you if you are unable.

30. Life Sustaining Procedures You Authorize to be Withheld:

CLIENT 1: Respiration: [ ] Yes [ ] No

Nutrition (Feeding Tube): [ ] Yes [ ] No

Hydration (IV): [ ] Yes [ ] No

CLIENT 2: Respiration: [ ] Yes [ ] No

Nutrition (Feeding Tube): [ ] Yes [ ] No

Hydration (IV): [ ] Yes [ ] No

31. Who do you wish to act as your health care surrogate/agent? CLIENT 1: CLIENT 2:







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ASSET INFORMATION

32. Real Estate: If you own real estate, please list the address in the appropriate space(s) below. Indicate how it’s owned, if you know (Sole Owner, Joint Tenant, Tenant in Common, Tenant By the Entirety, etc.). Please bring a copy of the deed, if you have it. CLIENT 1: CLIENT 2:

Primary Residence: Address: _________________________________ ________________________________________ Owned as: _______________________________ Approximate market value: __________________

Primary Residence: Address: _________________________________ ________________________________________ Owned as: _______________________________ Approximate market value: __________________

Other Real Estate: Address: _________________________________ ________________________________________ Owned as: _______________________________ Approximate market value: __________________






33. Mortgages: Do you currently hold a mortgage on your home or any other residences? If so, please list it here. CLIENT 1: CLIENT 2:

Bank: ___________________________________ Account #: _______________________________ Property Mortgaged: _______________________ ________________________________________ Amount owed: ____________________________


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34. Bank Accounts: Please list all bank accounts in your name, indicating whether they are “Held As” a single name, joint accounts, in Trust for, or custodial accounts. If you don’t know which kind it is, make a copy of the first page of your last statement, and this may help us figure it out. All accounts should be listed, including those held jointly with a spouse, a child, grandchild, sibling, or other person. If the account is a certificate of deposit, please note “CD” next to the listing. Not all assets are considered part of your estate, but you should list them here so that we may review them.

CLIENT 1 BANK ACCOUNTS: CLIENT 2 BANK ACCOUNTS:

Bank: ___________________________________ Account # (or last four digits): ________________ Names on Account: ________________________ ________________________________________ Held as: _________________________________

Bank: ___________________________________ Account # (or last four digits): ________________ Names on Account: ________________________ ________________________________________ Held as: __________________________________


Bank: ___________________________________ Account # (or last four digits): ________________ Names on Account: ________________________ _________________________________________ Held as: __________________________________


Bank: ___________________________________ Account # (or last four digits): ________________ Names on Account: ________________________ _________________________________________ Held as: __________________________________



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35. Stocks, Bonds, & Mutual Funds: List all stocks, bonds, mutual funds, and savings bonds you own. If you own stocks or bonds, do you hold the certificates? CLIENT 1: CLIENT 2:

Company/fund: ___________________________ # of shares: _______________________________ Price paid: _______________________________ Current value: ____________________________ Name on Certificate: _______________________






36. Annuities: List any annuities you hold, including pensions that will pay a fixed monthly amount over time. If you don’t know, find out if the annuity guarantees a minimum number of payments if you should die soon after it starts paying. CLIENT 1: CLIENT 2:

Company: ________________________________ Current value: ____________________________ When it began paying: ______________________ Monthly payment amount: ___________________ Beneficiary: ______________________________




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37. Retirement Accounts: Please list all IRAs (Individual Retirement Accounts), Keogh Plans, or other retirement accounts over which you have access to the principal. CLIENT 1: CLIENT 2:

Bank: ___________________________________ Custodian Account #: _______________________ Whose Account?: __________________________ Balance benefit upon death: __________________






38. Life Insurance: Please list all life insurance policies.

CLIENT 1: CLIENT 2:

Name of company: _________________________ Name of insured: __________________________ Policy number: ____________________________ Death/face value: __________________________ Cash value: _______________________________ Beneficiary: ______________________________




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39. Motor Vehicles: Indicate here whether you own any motor vehicles. CLIENT 1: CLIENT 2:

Make/model/year: _________________________ Registered to: _____________________________ Estimated value: ___________________________ Paid off? [ ] Yes [ ] No






40. Do you have a safe deposit box?


Bank: _______________________________________ Branch location: _______________________________ In whose name?:_______________________________ Other agent: __________________________________ Contents and estimated value: ____________________ _____________________________________________ _____________________________________________


Bank: _______________________________________ Branch location: _______________________________ In whose name?:_______________________________ Other agent: __________________________________ Contents and estimated value: ____________________ _____________________________________________ _____________________________________________

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DEBTS

41. Debts Owed to Me: Do you currently hold a mortgage to property you sold to someone else? Do you have any other outstanding loans owed to you? Are they secured against property? Is the party who owes the money to you also a beneficiary under the will that you want to prepare? If so, do you want that individual to repay the bill, or should the bill be forgiven? CLIENT 1: CLIENT 2:

Debtor: __________________________________ Description: ______________________________ Security/property: _________________________ Balance due: ______________________________




42. Debts Owed by Me: Do you owe money to anyone? Do not include a mortgage here. If

you currently hold a mortgage, please list it under number 33. CLIENT 1: CLIENT 2:

Name: __________________________________ Description: ______________________________ Balance due: ______________________________






THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

_________________________________________ ______________________________ CLIENT 1 Signature Date _________________________________________ ______________________________ CLIENT 2 Signature Date

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